Evaluation of Continuity of Care: What Can Physician Survey Add?

Introduction

Strengthening continuity of care is critical to achieve its high outcomes. A growing number of people with chronic diseases and long-term conditions require not only more diverse and complex medical interventions but also a close interaction of care providers to ensure a smooth progress of patients in the health system [1]. According to Haggerty et al. [2], “continuity is the degree to which a series of discrete health care events is experienced as coherent and connected, and is consistent with the patient’s medical needs and personal context”. It means that health care is not limited to one contact with health provider and one episode of care but relates to patients needs longitudinally and at various stages of service delivery. Continuity is a major characteristic of care integration, together with teamwork and coordination of care [3]. Moreover, it is a major focus of strengthening integration: “coordination and teamwork is what providers do for the benefit of continuity” [4]

There is a consensus on three types of continuity. Informational continuity means that a provider has an access to all relevant information about patients’ utilization of care at all stages of their “route” in the health system. Longitudinal continuity means that it transcends multiple episodes of disease, and interpersonal relates to a trustful relationship of patients and providers [5]. Sometimes interpersonal continuity is used as a proxy measure for the strength of patient-physician relationships [6].

A substantial body of literature addresses the impact of continuity on health systems performance. There is an evidence that a frequency of contacts with one doctor is a strong factor of patient satisfaction, improved health promotion [7, 8]. Many studies report reductions in mortality, with increased interpersonal continuity of care. A well-organized post-discharge care at home decreases utilization of inpatient care and mortality [9].

Another body of literature focuses on evaluating continuity. It addresses mostly the interpersonal continuity and measures the frequency of patient contacts with providers using Continuity of Care Index, Usual Provider Continuity Index, etc. [10, 11]. These studies are based on the statistical data, patient assignment data systems, surveys of patients. But such measurement technique has some limitations. Quantitative indexes don’t characterize fully the complex nature of interactions between providers and patients, as well as between providers (longitudinal and informational continuity). Many low and medium income countries do not have accurate patient assignment data systems, while statistical data is often not available to the public.

The recent OECD study [12] has contributed to the measurement of integration by suggesting three indicators with the focus on care continuity: mortality, hospital readmissions and prescribed medicines for post-discharge care in stroke and congestive heart failure patients. The measurement was based on patient-level data across various datasets. This study covered 15 countries and provided useful results in collection of comparative data. The Commonwealth Fund study [13] is another attempt to compare integration in 11 OECD countries. The survey queried primary health care physicians about their ability to coordinate patients’ medical care with specialists, across settings of care, and with social service providers. The survey was based on the nationally representative samples of physicians.

The objective of this paper is to get additional information on the continuity of care in Russia by a newly developed physician questionnaire. Contrary to the international studies, it is designed to evaluate a substantial number of characteristics and indicators of informational, longitudinal and interpersonal continuity of care. We want to show what specifically can be assessed with physician survey, as well as the limitations of this evaluation instrument in the context of the Russian Federation and internationally.

Following is a summary of the specific characteristics of care organization in Russia related to the evaluation of care continuity: 1) Most of primary and outpatient specialty care is provided in multi-specialty polyclinics. The interaction of generalists and outpatient specialists exists “under one roof”. The referrals for outpatient care to external entities are relatively rare. This facilitates but does not guarantee teamwork and continuity of care [14]. 2) The hospital sector is built as a multilevel system, with rural, central rayon, city, regional and federal hospitals closely linked through a referral system from one level to another, while outpatient and inpatient care is usually provided by different doctors [15]. 3) The distinction between acute and long-term hospitals does not exist in Russia. Nursing homes and similar post-acute institutions are rare [15]. The links between the two are not clear. 4) Emergency care is provided by stand-alone entities – stations of medical emergency. They are supposed to communicate with polyclinics and hospitals. Emergency care units of hospitals, typical for many Western countries, are rare in Russia. 5) Social care is developing as a separate sector. Polyclinics and hospitals can refer their patient to social facilities, but there are many barriers to their joint activities [14]. 6) There is a sector of spas, where patients can be referred by polyclinics for rehabilitation. However, a chronic underfunding of health care (public health funding is only 3.5% of GDP) limits the development of this sector and its links with polyclinics; 7) Service delivery is increasingly influenced by electronic medical cards. But the scale of this process is still limited [15].

Bearing in mind some integrative features of health care, Russia is a good case for the evaluation of care continuity. The major research question is how physician survey can contribute to this evaluation. The first attempt was made in 2014 [3], while it covered a limited number of continuity characteristics, and the questionnaire had only four questions on this subject. This paper is a continuation of the study.

Methods and data

We followed a three-step methodological framework: 1) the choice of major characteristics of three types of continuity (informational, longitudinal and interpersonal) for their evaluation; 2) developing questions for each characteristic; 3) designing a physician survey.

Results of the survey

Below is the summary of findings for each type of care continuity. We estimate the percentage of responses to the questions by all respondents or their specific group – hospital doctors or polyclinic physicians. The latter include polyclinic managers (they are always physicians). The references are made to the respective figures with the detailed distribution of physicians’ responses to the questions that are given in the appendix (supplementary materials). The absolute numbers can be obtained through the communication with the authors.

Informational continuity

Access to comprehensive electronic medical records. Only 28.5% of polyclinic physicians report that all electronic medical records made in their region are accessible. 28.1% have an access to all records made only in their facility, 17.9 – to some fragmented records, while 18.8% of responses don’t have an access to any electronic records (Figure 1).

Figure 1

Level of polyclinic physicians’ awareness of the current hospital admissions of their patients. Only 19.6% of polyclinic physicians report that their polyclinic receives information about all admissions and 10.7% – about more than 50% of admissions. 28% of respondents have a fragmented information and 18.5% don’t have any (Figure 2). If to assume that 23.9% of respondents who find it difficult to answer the question are close to the group that gives the answer “Don’t receive at all”, then we can conclude that the level of informing polyclinic physicians is low: they receive information about the hospitalization of their patients approximately only in every fourth case.

Figure 2

Level of polyclinic physicians’ awareness of the current contacts of their patient with organizations (units) of emergency care. Half (50.4%) of physicians report that their polyclinics are notified of all emergency contacts of their patients. The share of those who are not informed at all is only around 10% (Figure 3).

Figure 3

Hospital physicians’ contacts with polyclinic physicians. The question of the survey is focused on the contacts before admission and in the course of inpatient care. More than third of hospital physicians (34.3%) never contact their polyclinic counterparts, 50.6% contact “rarely’ or “sometimes”. The share of those who do this “always” and “often” is 11.7% (Figure 4).

Figure 4

Frequency of consulting polyclinic physicians by hospital doctors on managing patients after hospital discharge. The survey indicates that 38.2% of polyclinic physicians don’t have any consultations and 33.1% have them “rarely”, while only 14.2% often use this opportunity. Similar question addressed to hospital doctors gives more optimistic estimates: 22.7% – “often”, 40.8% – “rarely” (Figure 5).

Figure 5

Frequency of the feedback from spas to a referring physician on the results of treatment. Only 23.2% of polyclinic physicians report that receive this information “always” or “sometimes”, while 47.3% – “never” or “rarely” (Figure 6).

Figure 6

Longitudinal continuity

Use of unobstructed patients’ management technologies. Polyclinic physicians are questioned about the availability of the practice of home visits to the patients with stroke and heart attack the first days after discharge. 45.5% of physicians report positively without clarification how often, while the rest does not confirm such visits (Figure 7). These responses relate to physicians visits. The visits of nurses to such patients are practiced rarely because of their limited clinical capacity [16].

Figure 7

Level of hospital readmissions due to inappropriate management of patients by polyclinic physicians. 30.3% of hospital doctors report that they run into this all the time, while 50.7% – “in single cases”. Only 6.1% never face such cases (Figure 8).

Figure 8

Frequency of timely transfers of patients from acute hospitals to rehabilitative care and long-term social care facilities. Only 20.6% of hospital doctors report that their patients can “always” or ‘often” be transferred to rehabilitative inpatient units, while 57.4% report that such transfers rarely happen and 14.6% never transfer their patients to such facilities (Figure 9). Similarly low is the frequency of patients’ transfers to long-term social care institutions (Figure 10).

Figure 9

Figure 10

Share of acute hospital beds occupied by patients who need a transfer to the rehabilitative and long-term care entities. A low percentage is an indication of a smooth progress of patient in the health system. This is not the case in Russia. 33.5% of hospital doctors report that this share is higher than 10% (22.1% – from 11 to 30% of hospital beds). 40.9% of respondents make a more optimistic estimate of less than 10% of beds (Figure 11).

Figure 11

Physicians’ satisfaction with the degree of continuity of care provided in various types of medical facilities. The opinions of all physicians questioned on the level of continuity of care in their regions are divided: only 8.6% consider it “high”, 36.8% – “medium”, and almost half (46.8%) – “low” (Figure 12).

Figure 12

Interpersonal continuity

Comprehensiveness of care provided by district physicians. Only 29.7% of respondents of the survey report that district physicians refer less than 10% of primary patients. 60.6% of our respondents urge that the frequency of referrals is much higher: 27.8% – from 11 to 25% of patients, 32.8 % – more than 25% patients (Figure 13).

Figure 13

Availability of chronic disease management activities. We set the question “Are schools of chronic patients organized in your polyclinic?” and addressed it to polyclinic physicians. 36.1% of respondents reported negatively and 16.5% – “don’t know”, while nearly half confirmed the availability of such activities (Figure 14). The questions related to the patients’ coverage, a set of specific services and health outcomes of these schools remained without answer.

Figure 14

Initiatives of PHC physicians to involve social workers to the management of patients with substantial health needs. To determine the degree of such activities, we asked a question “Do you approach social care providers with the request to help your patients?” and addressed it to policlinic physicians. 16.4% report that such initiatives happen “often”, 36.2% – “sometimes” and “rarely”, while every third physician (36.5%) never approaching social workers. Probably, 10.8% of respondents who have problems with the answer are close to the latter (Figure 15).

Figure 15

Discussion

The study demonstrated that physician survey can add to the evaluation of continuity of care. It differs from those in the above mentioned OECD study [12] and Commonwealth Fund online survey [13]. Following are the major distinctions:

• Our indicators of continuity are focused on the characteristics rather than outcomes of continuity of care, like mortality and readmissions. We explored the gaps in the movement of information and patients in the health system by asking questions about the specific areas of communication between providers. Our list of questions is much longer than in other physician surveys.

• Contrary to other studies, our questionnaire is designed to characterize the types of continuity – informational, longitudinal and interpersonal. This is important to understand specific interactions in the health system.

• We address questions to the predefined categories of physicians (those working in outpatient and inpatient settings) who can professionally make estimates of their specific areas of interactions with other providers. Collecting responses of the “average” physician may distort the responses to many questions.

• Most of our questions are not disease-specific, while the OECD study is focused on two specific health problems [12]. The latter approach is preferable. But it can provide robust estimates only when reflects specific pathways of patient progress in the system. A broad question about the availability of prescribed medicines for post-discharge care is not enough to characterize care continuity.

The limitations of our study lie in its design. A small online survey with the pre-determined minimum number of respondents does not allow to ensure a high representativeness of the sample. It is skewed to young and urban respondents who are more interested in the problem and more active as respondents. The biggest cities of Russia are over-represented, while the structure of respondents across types of care represents the actual structure of physicians in the country. To cope with the limitations of small-scale online survey is difficult. The major instrument is to monitor the intermediate stages of the survey and then repeat invitations to under-represented categories of physicians.

The list of continuity characteristics is not exhaustive. Other characteristics can be added. For the longitudinal continuity, it is possible to explore the following:

• – clarity of patients “routes” in the multi-level system of service delivery: are providers aware of the most appropriate next step in the chain of services?

• – availability of care coordinator. This is an indication of the attempt to avoid problems at the “junctions” between individual providers and bring together multiple episodes of patient management;

• – availability of barriers between public and private providers. They may exist in the countries with the dominance of state owned medical facilities and the variance in the regulation of public and private providers. For example, when there is no requirement of the feedback of private specialists to generalists in public facilities, which is the case in Russia.

For the analysis of interpersonal continuity, GPs’ awareness of their patients’ current health status (particularly patients with complex health needs) can be evaluated. It is also important to evaluate care continuity for vulnerable groups (long-term care residents, people suffering from mental health conditions, etc). The analysis of longitudinal continuity can be strengthened by the evaluation of long-term patient trajectories in the system, for example, the movement of patients with oncological diseases from the moment of initial diagnosis to the start of treatment process. To make a study more comprehensive, a more detailed survey of physicians is needed.

The attempt to determine the role of polyclinic physicians in the management of patients with stroke and heart attack the first days after discharge was not totally successful: most of respondents could not make the estimate of the availability of outpatient care in two weeks time after hospital discharge. Thus the frequency of the follow-up outpatient treatment of such patients remains unclear. With all these limitations, a small online survey provided the opportunity to test the questionnaire and receive some preliminary results. It indicates that the level of care continuity in Russia is low. Access to electronic medical records is limited. Most physicians can share information electronically only with other units of their facility and don’t have a comprehensive picture of health care utilization by their patients. Outpatient and inpatient physicians rarely contact with each other. Polyclinics physicians are unaware of the substantial part of hospital admissions and emergency visits of their patients, which makes them unprepared for the follow-up treatment. Home visits to patients with heart attack and stroke after hospital discharge are rare. The lack of timely transfer of hospital cases to rehabilitative and social care settings also limits continuity of care. The low comprehensiveness of care provided by DPs is a substantial barrier to interpersonal contacts with patients. These findings need to be tested with the use of more representative sample.

The survey based on the specific questions on care continuity can be used for the international comparisons. Following are the major aspects of our survey that can contribute to such comparisons:

• – division into types of continuity;

• – determining characteristics for each type;

• – avoiding broad indicators;

• – using most of our questions, with the exclusion of the country-specific questions, for example, the question about feedback of spas to polyclinics;

• – addressing questions to the predefined categories of physicians;

• – developing uniform requirements to the size of the sample and representativeness of respondents groups across countries.

Conclusion

The physician online survey can provide additional information on the continuity of care in Russia. It revealed the important zones of fragmentation in the health system that was originally designed as integrated. The survey was designed to increase the number of characteristics and indicators for the evaluation and to make estimates of informational, longitudinal and interpersonal continuity, including specific areas of provider interactions in the health system. The content of the suggested survey can be valuable for collecting an international evidence of continuity and international comparisons. However, a small scale of the survey and its online operation limit its representativeness and robustness. Special activities are needed to overcome the limitations. Bigger scale of the survey with the same or similar questionnaire can improve its results.

Additional File

The additional file for this article can be found as follows:

Reviewers

Pr. Dr. Geert Goderis, Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium.

One anonymous reviewer.

Competing Interests

The authors have no competing interests to declare.